840 3rd Avenue South, St. Petersburg, FL 33701

Telephone: (727) 825-3710; Fax: (727) 825-3751

Name: ______

Registration Checklist

As a student seeking registration to MYcroSchool,

please submit the following documentation in order to be enrolled in the school:

______AM session 7:30-11:30 am ______PM session 12:30-4:30 pm

All forms are required and need to be fully completed, unless otherwise noted:

______Student Information

______Parent/Guardian Information

______Emergency Contact List

______Home Language Survey

______Official Request for Student Records

______ Photo Release Form

______E-rate Survey

______Letter from Superintendent

______Signed Acknowledgment Form

______Students’ Picture ID (Driver’s license, Florida ID, Student ID, or Passport)

______Students’ Birth Certificate

______Students’ Social Security Card

______Proof of Pinellas County Residency (Utility Bill)

______Proof of Florida Health Shot (immunization) Records

______Meal Benefits Application (red)

______Student Clinic Card & Release Form (medical form) (blue)

How did you hear about MYcroSchool?

□Student referral □ School referral □ Community referral □ other ______

Name of school: ______(Specify)

For Office use only: Orientation Date: ______MUST BE IN UNIFORM

Completed Orientation: Y N No Show

MYcroSchool Representative: ______Date: ______

Your Age Today: ______

Student Information

Student Legal Name(Last, First, Middle I) Student Former Name or AKA
Address City State Zip
Student Soc. Sec.#(optional) / Home Telephone# / Best Contact during day
Student’s Email: / Parent/Guardian Email:
Student Race/Ethnic Origin □ W-White, Non-Hispanic □ H-Hispanic □ A-Asian/Pacific Islander
□ B-Black, Non-Hispanic □ M-Multiracial □ I-American Indian/Alaskan Native
Student Gender
□ M □ F / Student Date Birth (mm/dd/yyyy)
Student Origin of Birth
□USA Other:______; ______City ____State / If student’s country of birth is not USA
What date did the student enter USA?______

PREVIOUS EDUCATION INFORMATION

Name of Last School Attended / Last School attended Telephone / School Type (Circle One)
Public or Private
City and County of Last School Attended / State of Last School Attended
Educational Plan If applicable. Check all that apply. Provide a copy of the plan with this registration.
□ Individual Education Plan (IEP) □ 504 Plan □ Other Plan ______
Highest Grade Completed / Grade Level This Year / Last Year Attended
School / Did the student attend school in Pinellas County before? □ Yes □ No

ENTRY DISCLOSURES (check all that apply)

□ The student has had juvenile justice actions taken against him/her. □ The student has been expelled from school.
□ The student has been arrested, resulting in a charge. □ Not applicable
REGISTRATION IS NOT VALID WITHOUT SIGNATURE
REGISTRATION IS NOT VALID WITHOUT SIGNATURE AND DATE. Under penalties of perjury, I declare that I have read the foregoing form and that the facts stated in it are true and accurate. Florida Statutes Sec.92.525 (3) provides that whoever knowingly makes a false declaration under penalties of perjury is guilty of a felony of the third degree.
______
Signature of Parent/Guardian Date
Students First Name / Students Last Name

PARENT/GUARDIAN INFORMATION

Mother or Guardian / Last, First Name / Cell #
Day # / Night #
Address if not the same as student (house#, street name, apartment #,city, state, zip code)
E-mail address (optional)
Father or Guardian / Last, First Name / Cell #
Day # / Night #
Address if not the same as student (house#, street name, apartment #,city, state, zip code)
E-mail address (optional)
IMPORTANT, EVERYONE MUST ANSWER QUESTIONS A & B BELOW
A.  Is there a visitation order or other court order barring either parent from removing the student during the school day or coming into contact with the student? If YES, provide school with a copy of court order. □ Yes □ No
B.  Do parents have shared parental responsibility? □ Yes □ No

______

Parent/Guardian signature required

MYcroSchool

Emergency Contact Information

Student Name ______

Emergency Contact Information #1

Name ______

Relationship to Student ______

Home Phone ______Cell Phone ______

Work Phone ______

Emergency Contact Information #2

Name ______

Relationship to Student ______

Home Phone ______Cell Phone ______

Work Phone ______

Emergency Contact Information #3

Name ______

Relationship to Student ______

Home Phone ______Cell Phone ______

Work Phone ______

______

Parent/Guardian signature required


Official Request for Student Records

TO: ______(Last School) Fax #:______

The above student is seeking registration to MYcroSchool. The student has identified your school as the previous school attended. Please forward the following records upon receipt of this request.

______Withdrawal Form with Current Grades

______Official Transcripts

______Cumulative Folder (if previous school was in Pinellas County)

______Copy of Individual Education Plan or English Language Learner LEP Plan

______Copy of FCAT/ACT/EOC test score report

Comments:______

Request submitted: ______By: ______

Date of Receipt: ______

Date entered into PowerSchool:______

Photo Release

I hereby grant SIATech, NEWCorp, MYcroSchool, RAPSA, NEWGlobal, and its legal representatives and assigns (including but not limited to), clients, publications and agencies, irrevocable permission to use my academic work, graduation speech, photo and video in any manner, including (but not limited to) online, print, and other media. I will hold harmless SIATech and all affiliated organizations from any liability by virtue of distortion or alteration, unless it can be proven that such alterations and or distortions were done with malicious intent. The academic work, graduation speech, photo, or video will not be sold in anyway.

I ______(student or parent of minor) have read and fully understand the contents of this release. I declare that I am or may be over the legal age of 18, and am fully competent to sign this release.

Student Name: ______

School Site: ______

Home Address: ______

City: ______St: ______Zip: ______

Email Address (optional):______

Parent of minor signature: ______

Students’ signature: ______

Date: ______

MYcroSchool Witness: ______

E-Rate Discount Family Survey

E-Rate is a federal program that provides significant discounts on purchasing modern technology for our classrooms. We need this survey completed in order to qualify for greater discounts. This information will only be used to determine the discount for the school, and will not be made public.

Please circle Yes or No for each question:

1.  Are your children eligible for the NSLP (National School Lunch Program) which provides free or reduced lunches, breakfasts, snacks, or milk at your school(s)?

Yes No

2.  Is your family eligible for food stamps? Yes No

3.  Is your family eligible for medical assistance under Medicaid? Yes No

4.  Does your family receive Temporary Assistance for Needy Families? Yes No

5.  Does your family receive Supplementary Security Income? Yes No

6.  Does your family receive house assistance (section 8)? Yes No

7.  Does your family receive home energy assistance (LIHEAP)? Yes No

Total number of family members (count mother, father, and all children): ______

Please circle the amount which best represents your family’s annual income.

$0-$19,240 $19, 241-$25,900 $25,901-$32,560 $32,561-$39,220

$39,221-$45,800 $45,801-$52,540 $52,541-$59,200 $59,201+

Please list the names and grades of all school children living in your home. Include the name of the school where they attend. If you need more room, please use the back of this form.

Name of child / School / Grade

Linda C Dawson, Ed.D.

Charter School Superintendent/CEO

Martina Green

Principal, MYcroSchool Pinellas

Dear MYcroSchool Student,

School attendance is critical to your success in school and helps you develop good work habits that will carry over in life. In addition, your success is directly related to your attendance in school. The responsibility of school attendance is that of both parent(s) and student. The school strives to be fair and understanding with all students in the area of absences.

Per Pinellas County Public Schools attendance policy, students who accumulate fifteen or more unexcused absences in a ninety calendar day period shall be considered truant and may not be able to graduate. In addition, students who attend charter schools and have fifteen consecutive, twenty cumulative or more unexcused absences, and three tardies which counts as one absence, may be sent back to their home school due to insufficient attendance.

Student’s Printed Name: ______

Student’s Signature: ______

Acknowledgment Form

Dear MYcroSchool Administration,

As the parent/guardian of ______, I am acknowledging that MYcroSchool Pinellas is a dropout recovery program with documented success in re-engaging students in the educational process and credit recovery. I understand that my child will earn a bus pass to ride city transportation to and from school as long as he/she abides by the attendance policy.

I give permission for my child to be enrolled in this educational program model so that he/she can work towards earning a high school diploma.

Sincerely,

______

Print Name (Parent/Guardian)

______

Sign Name (Parent/Guardian)

Revised 3/2/15